Clinical Report: Endoscopic Vacuum Therapy in Upper GI Tract Defects

Overview

Endoscopic vacuum therapy (EVT) is an evolving technique for treating transmural wall defects in the upper gastrointestinal tract, particularly effective for anastomotic leakages after oncological and bariatric surgeries. EVT offers higher closure rates, shorter treatment durations, and lower mortality compared to stenting, with growing evidence supporting its use in esophageal and esophago-gastric junction defects.

Background

EVT originated from external vacuum wound therapy used by plastic surgeons and was adapted for endoluminal use initially in the lower GI tract. It involves applying negative pressure to a wound compartment via an airtight seal, promoting wound shrinkage, granulation, and drainage. The technique has been standardized with devices like the EsoSponge® system since 2014. EVT is increasingly recognized as a standard treatment for foregut wall defects, especially in European centers of expertise.

Data Highlights

Negative pressure of 125 mmHg can reduce polyurethane sponge volume by up to 80%, facilitating wound cavity collapse (macro-deformation). Studies show EVT has higher anastomotic leakage closure rates, shorter treatment durations, and lower mortality compared to stenting. EVT devices typically require exchange every 3–5 days, and patients must remain nil by mouth during treatment.

Key Findings

• EVT is indicated for transmural wall defects of the esophagus and esophago-gastric junction, including suture line leaks post-oncological and bariatric surgery, iatrogenic perforations, and spontaneous ruptures like Boerhaave’s syndrome.
• Compared to endoscopic stenting, EVT demonstrates higher closure rates of anastomotic leaks, shorter treatment duration, and lower mortality in retrospective studies and meta-analyses.
• EVT promotes wound healing via macro-deformation (wound cavity collapse) and micro-deformation (granulation tissue formation), as well as drainage of infected fluids and reduction of edema.
• Limitations include difficulty in creating an airtight seal in proximal esophagus, hypopharynx, and large gastric lesions, and the need for repeated endoscopic interventions and patient fasting during therapy.
• EVT can convert intestinal wall defects communicating with other body cavities into contained situations, critical for sepsis management.
• The EsoSponge® system has standardized EVT application in the foregut since 2014, facilitating broader clinical adoption.

Clinical Implications

Clinicians should consider EVT as a first-line endoscopic treatment for upper GI transmural defects, especially anastomotic leaks, due to its superior efficacy and safety profile compared to stenting. Patient selection must account for anatomical limitations and the need for repeated endoscopic procedures. EVT’s ability to drain infected cavities while promoting wound healing can improve outcomes in complex foregut leaks and perforations.

Conclusion

EVT represents a significant advancement in managing upper GI transmural defects, offering effective closure and enhanced healing through negative pressure mechanisms. Its adoption is supported by growing clinical evidence and device standardization, positioning EVT as a key therapeutic modality in foregut surgery complications.

References

1. Loske et al. 2014 -- Introduction of EsoSponge® system for EVT
2. Meta-analyses 2011-2021 -- EVT vs. stenting outcomes
3. Plastic Surgery Vacuum Therapy Origins, 15 years ago